High grade fever with chills and swelling of the eyes

Q:Sir, I am presenting a case of 18 yr old male farmer who came with c\o of intermittent high-grade fever(105 degrees F) with chills but no rigors. Sweating for 1 month, swelling for 15 days starting from face and progressing to the legs over 2 days but periorbital swelling is disproportionate rest of the swelling and there is bilateral chemosis of eye bulbs. There is no h\o cough, haemoptysis, chest pain, weight loss. No h/o bone pain, joint pain, morning stiffness. No h/o flank pain, dysuria, pyuria, jaundice, pain abdomen, rash or features of vasculitis. There is history of treatment by a local
practioner with antimalarials, IV Ceftriaxone 2 gm bd for 5 days, Wysolone and Paracetamol. On examination: No pallor, icterus, cyanosis, rose spots. Facial puffiness is present with periorbital odema and chemosis. Sir, could you give me any valuable suggestion regarding other possible differential diagnoses and
proper management.

A:It is one of those occasions when one wishes that one had a sight of the patient. In fact, the golden rule for a pyrexial problem with undetermined cause is that the patient must be examined every day; there might be a clue in the history that the patient may have previously forgotten and a new sign may have appeared. It is not clear whether the swelling of the legs is oedema or like the periorbital swelling, which may due to an infection, allergy or cavernous sinus thrombosis. A CT scan of the head would be useful. You do not mention what his serum albumin level is. Oedema and proteinuria are not specific indicators of any form of nephritis. Does his urine contain any red cells and casts? In a patient who has had intermittent high grade fever with chills and sweating, we must consider infection at the top of the list followed by a number of possibilities including lymphoma, malaria, a collagen disorder, or any other malignancy. A single sterile blood culture does not rule out infection nor does a single negative thick blood smear rule out malaria. You need several blood cultures in a 24 hour period. There is a wide variety of infections in India that might cause a pyrexia of the type your patient has, and so far you have only excluded typhoid which, incidentally, does not cause intermittent pyrexia. A CT scan of the abdomen would also be desirable in case he has an abscess, enlarged lymph nodes or any other malignancy. Have you considered biopsying one of the enlarged lymph glands in the neck? You will need to exclude or establish one of the diagnosis you already have on the list before adding more conditions. It is not easy (such cases never are) but patience and persistence will hopefully reward you.